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Incidence and Outcomes of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting in Patients with Diabetes and Multi-vessel Coronary Artery Disease
Nahush A Mokadam1, Rayland Melford, Jr.1, Charles Maynard1, Richard Goss1, Douglas Stewart1, Mark Reisman2, *Gabriel S Aldea1
1University of Washington, Seattle, WA;2Swedish Medical Center, Seattle, WA
BACKGROUND: Despite a paucity of supporting data and established guidelines, percutaneous coronary intervention (PCI) is used with increasing frequency in higher-risk patient populations. Results and outcomes of this strategy in clinical practice remain unknown. The study uses the State of Washington’s database and aims to define the incidence, outcomes and trends of coronary artery bypass grafting (CABG) and PCI in patients with multi-vessel coronary artery disease (CAD) and diabetes mellitus (DM).
METHODS: The State of Washington Clinical Outcomes Assessment Program (COAP) is a prospective clinical database that captures all revascularization procedures (PCI and CABG) and was used to assess and compare the incidence, risk profiles, hospital outcomes and trends of all diabetic patients with multi-vessel CAD (defined as >= 2 vessel CAD with proximal LAD disease) undergoing first time revascularization (no prior intervention). Statistical analysis was conducted using SPSS software and categorical variables were compared with the Chi-squared test and continuous variables were compared with the student’s t-test.
RESULTS: 154,602 patients underwent revascularization in the state of Washington between from 1999 through 2007. 31.6% had multi-vessel CAD (48,860 of 154,602). 11,602 patients with DM and multi-vessel CAD underwent revascularization and were reported to COAP from 1999-2007 and were nearly equally divided between CABG (51%) and PCI (49%). 27.6% (5992 of 21746) of patients undergoing CABG and 20.7% of PCI (5610 of 27114) with multi-vessel CAD had DM. Compared to PCI, patients undergoing CABG had a higher statistically significant (p<0.0001) incidence of congestive heart failure (24% vs. 18%), cerebrovascular disease (16% vs. 14%), peripheral vascular disease (17% vs. 14%), 3-vessel CAD (74% vs. 35%),and intra-aortic balloon pump insertion (5.6% vs. 1.7%), but a lower statistically significant incidence of female gender (30% vs. 40%), cardiogenic shock (1.7% vs. 4.3%) and emergency procedures (4% vs. 23%). In the non-emergent setting (elective and urgent), patients undergoing CABG had significantly more 3-vessel CAD (74% vs. 35%, p<0.0001), more complete revascularization (3.5±1.1 vs. 1.5±0.7 lesions treated, p<0.0001) but a higher mortality (2.3 % vs. 1.1%, p<0.0001). Other characteristics are summarized in the Table. Further, the incidence of PCI increased from 37.5% to 53.7% over the most recent 4 years.
CONCLUSIONS: PCI is applied with increasing frequency to patients with DM and multi-vessel CAD. PCI is used most commonly in patients with 2-vessel CAD or with acute (emergent) coronary syndromes with a strategy of more limited and targeted revascularization. CABG is more commonly applied to patients with more extensive disease with more complete revascularization. As both the incidence and percentage of patients undergoing PCI as primary therapy for multi-vessel disease with DM is increasing, long-term consequences of these treatment strategies remain to be defined.
Results of Revascularization | CABG (n=5992) | PCI (n=5610) | p | | Vessels Bypassed/ Lesions Treated | 3.7+/-1.1 | 1.4+/-0.6 | <0.0001 | | Hospital Death | 2.6% | 3.4% | 0.013 | | Stroke | 1.7% | 0.5% | <0.0001 | | Dialysis | 1.9% | 1.0% | <0.0001 | | Hospital Stay (days) | 6.7+/-6.3 | 2.7+/-4.0 | <0.0001 |
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